Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Collect More Than Half A Billion Dollars In 2009

May 26, 2010, WASHINGTON - Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of more than $510 million in 2009, according to data released today by the Blue Cross and Blue Shield Association (BCBSA).  This represents a significant increase compared to 2008, and contributed to a three-year average return of $7 dollars for every $1 dollar spent on anti-fraud efforts.

BCBSA released the findings from its annual survey at a press briefing highlighting the Blue system's commitment to fighting healthcare fraud in an effort to save healthcare dollars and protect consumers.

"Blue Cross and Blue Shield companies are achieving significant gains in the war against healthcare fraud," said Scott P. Serota, CEO and president of BCBSA.  "Blue companies are actively identifying and pursuing healthcare fraud in partnership with federal and state authorities, law enforcement, and licensing boards.  These efforts protect consumers' healthcare safety and safeguard healthcare affordability.  Aggressive anti-fraud investigations help ensure critical healthcare dollars are being spent appropriately."

Joining Serota at the briefing were Peter Budetti, MD, JD, deputy administrator, Center for Program Integrity, Centers for Medicare & Medicaid Services; Greg Anderson, vice president, corporate and financial investigations, Blue Cross and Blue Shield of Michigan; Alanna Lavelle, director of investigations, WellPoint, Inc. Southeast and Central regions; and Lou Saccoccio, executive director, National Health Care Anti-Fraud Association.

The Blues have long maintained robust anti-fraud efforts as part of their commitment to improve the accessibility and affordability of healthcare services.  The recent healthcare reform debate shed light on the importance of these efforts, and the Blues' work complements the anti-fraud activities of the Department of Health and Human Services.

"Finding, reducing and preventing healthcare fraud in Medicare, Medicaid, CHIP and the private healthcare system is a high priority," said Peter Budetti, MD, JD, deputy administrator, Center for Program Integrity, Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services.  "Today's announcement emphasizes the value of these combined efforts to help reduce healthcare fraud and provides a sentinel effect of putting those inclined to commit fraud on notice."

Blue Cross and Blue Shield companies' anti-fraud investigators collectively prevented more than $318 million from being paid to fraudulent or erroneous medical claims, an increase of 62 percent over 2008.  In addition, the Blues' efforts resulted in the recovery of more than $192 million that had been paid to fraudulent and abuse claims - an increase of 28 percent from the previous year.

Other statistics from the BCBSA survey include:

  • 5,028 complaints were received by Blue anti-fraud hotlines;
  • 1,044 cases were referred to law enforcement officials;
  • 490 arrests and/or indictments resulted from Blue Plan referrals; and
  • 355 criminal convictions resulted from Blue Plan referrals in 2009.

"Coordination with state authorities and local law enforcement is a key focus of Blue Cross and Blue Shield companies' anti-fraud efforts," said Anderson, vice president for corporate and financial investigations and member of BCBSA's National Anti-Fraud Advisory Board.  "These efforts yield significant results and help defeat the sophisticated efforts of many fraud schemes.  In addition, an educated public is a huge boost to investigations.  We urge anybody with information concerning potential healthcare fraud to call the national hotline number."

Lavelle concurred, adding, "A close working relationship between public and private investigators is crucial to the rapid identification of fraudulent activities and subsequent, systematic action to ensure that critical resources are not diverted from the system."

Saccoccio urged consumers to take a more active role in preventing healthcare fraud by reading and understanding their Explanation of Benefits (EOB) and protecting their health insurance information.  "Consumers are the first line of defense in the battle against healthcare fraud," he explained.  "They need to recognize and report possible fraud when they are being billed for services they never received or services which are incorrect.  Their vigilance is crucial in fighting healthcare fraud."

Blue Cross and Blue Shield members can report suspected fraud through a national hotline number, 1.877.327.BLUE, and Web site (www.bcbs.com/blueresources/anti-fraud/report-fraud.html).  In addition, a brochure for consumers, "One Problem. 300 Million Victims. What You Need to Know About Healthcare Fraud," is located at:  www.bcbs.com/blueresources/anti-fraud/anti-fraud-consumer-brochure.pdf.  An interactive Explanation of Benefits tool is located at:  www.bcbs.com/blueresources/anti-fraud/explanation-of-benefits.html.

The webcast of this event can be viewed on: http://www.bcbs.com/news/bluetvradio/bcbs-companies-2009-aggregate-anti-fraud-statistics/.

The Blue Cross and Blue Shield Association is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for nearly 100 million members - one-in-three Americans. For more information on the Blue Cross and Blue Shield Association and its member companies, please visit www.BCBS.com.

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